Membership Application Form

Applicant’s Name: _____________________ Date: _______________
Address: ___________________
___________________
___________________
Phone: ___________________ Date of Birth: ______________
Physician’s Name: _______________________
Address: __________________________
__________________________
__________________________
Phone: ___________________

1. VISUAL ACUITY:

Distance Vision
WITHOUT CORRECTION WITH CORRECTION
Right Eye (OD ________ ___________
Left Eye (OS) _________ ___________
Both Eyes (OU) _________ ___________

2. VISUAL FIELD LIMITATION:

Central Vision: ____________
Peripheral Vision: ____________

3. Diagnosis:

______________________

4. Is the applicant legally blind?

Yes No

5. List golf experience:

_______________________________________
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Physician’s Signature: _______________ Date: _______________